Learn about front-line clinical informatics, clinical workflow design, and EMR implementation with an experienced CMIO. Open discussion is encouraged, education is a priority. All opinions are strictly my own.

Saturday, June 25, 2011

I've been speaking with various CMIO types, and Informatics types, and found an interesting pattern :

"Newbies" - Generally focused on the technology, the software, the bells-and-whistles

"Grizzled Veterans" - More focused on governance and change management.

In short, it's probably helpful if you have a little bit of both characters. You will need to worry about the software, the menus, the dialog boxes, the MLMs, your hosting, and your tablet computers if you want to garner support for your EMR implementation.

But when it comes to making organizational impact, nothing beats being a solid policy writer. A smart policy writer can have much more influence than the best politician/salesman in trying to organize things.

So even though I've written about policies before, I thought I'd write a little bit about the "tricks of the trade". This is the little trick you'll want to keep hidden, your lightsaber you'll carry on your belt. Only wield it when needed, and only use it for good.

POLICY TRICKS OF THE TRADE

The first thing, to really get solid with policy writing, is to really grok what a policy is. (For those of you who don't know the word "grok", it comes from Robert Heinlein's book, "Stranger in a Strange Land" - Wiktionary defines it as "to fully and completely understand something in all its details and intricacies.".)

A policy is your opportunity to set a standard. It's a document defining the standard.

The procedure (often linked to a policy by being on the same document) is the steps you take to achieve that standard.

Profound! You could, in fact, write a policy saying that you will be brought a coffee and donut every morning when you show up for work!

What would such a policy and procedure look like?

POLICY : All readers of Dirk's Blog will be brought a coffee and donut on their arrival for work in the morning, according to the procedure outlined below.

PROCEDURE :

Minion will bring money to store at 7am.

Minion will purchase (1) large coffee with cream and sugar.

Minion will purchase (1) chocolate glazed donut.

Minion will transport coffee and donut (described above) to office.

Minion will await arrival of Dirk's Blog Reader.

Minion will give donut and coffee to Dirk's Blog Reader, on their arrival.

It's really as simple as that. And yet, it's complicated...

It's complicated because people don't generally think that clearly without training. It's really easy to get clouded up, especially in healthcare, where you are trying to satisfy many regulatory issues, and dealing with very technical procedures.

But alas, I'm here to provide some guidance!

THE POLICY

The basic format of a policy can be written using this template :

[ who/what ] will [ what ] [ how ] [ when ] [ where ] [ why ]

Where : (blue = mandatory, brown = optional)

[ who/what ] = The person/thing that is being standardized

[ what ] = The standard that is being applied to the who/what above

[ how ] = How the standard will be achieved ("according to procedure below" is OK!)

[ when ] = Optional, only use if it helps clarify when the standard should be applied

[ where ] = Optional, only use if it helps clarify where the standard should be applied

[ why ] = Optional, only use if it helps clarify the purpose of the standard

Try it out! Here are some examples of good policy statements :

All patients will receive low-fat meals.

All patients over age 60 will receive a pneumonia vaccination before discharge.

All policies will be clearly written, according to the procedure outlined below.

All order sets will be evidence based and built according to the procedure outlined below.

And some examples of bad policy statements :

Patients should receive low-fat meals because it helps prevent heart disease. (Wordy, and never use the word "should" in a policy - "Will" is a stronger word!)

Pneumonia vaccines are helpful in preventing pneumonia, and so this will be given to any susceptible patients over age 60 before they are discharged by the nurse. (Too unclear and wordy!)

It is imperative that policies should be written in a manner consistent with easy comprehension. Policies should be developed in a clear, logical manner. Policies will be kept in the policy manual after approval. (Too wordy, vague, and starts to put procedure into the policy statement!)

All order sets will be evidence-based. (Nothing pointing a reader to the procedure below which, hopefully, explains how to build them in an organized fashion.)

Once you've mastered writing a good policy statement, you can proceed to the procedure.

THE PROCEDURE

The procedure is the "how to achieve the goal."

The best way to write a clear procedure is, again, to explain the who, what, when, where, how, and why, which together will tell you "how to achieve the goal".

Again, a template for thinking about it - You will need a series of steps :

[ who ] will [ what ] [ when ] [ where ] [ how ] [ why ]

[ who ] will [ what ] [ when ] [ where ] [ how ] [ why ]

[ who ] will [ what ] [ when ] [ where ] [ how ] [ why ]

[ who ] will [ what ] [ when ] [ where ] [ how ] [ why ]

[ who ] will [ what ] [ when ] [ where ] [ how ] [ why ]

... and so on ...

Where :

[ who ] = Person who will actually perform the task

[ what ] = Task they will perform

[ when ] = (usually optional) when / until when they will perform it

[ where ] = (usually optional) Where they will perform it - Only use if needed for clarity

[ how ] = (usually optional) How they will perform it - Use only if needed for clarity

[ why ] = (usually optional) Why they will perform it - Use only if really needed (rare)

Think of it as a recipe - In fact, most recipes are procedures! From Allrecipes.com you can find this New York Cheesecake Recipe and easily convert it to a procedure :

turn oven off and let cake cool in oven with the door closed for 5-6 hours

remove cake from oven and chill in refrigerator

And of course, in healthcare, this can be even a little more complicated, because you may have multiple characters. If you do, then you just have to separate the characters based on the role they will play in achieving your policy standard. For example, if the policy goal is "All dance performances by Fred Astaire and Ginger Rogers will leave audiences happy", then your procedure might be :

A. Fred Astaire will :

approach Ginger Rogers on dance floor.

listen to current music

choose dance style that is appropriate for current music.

lead dance that is appropriate for music.

B. Ginger Rogers will :

follow dance led by Fred Astaire.

demonstrate amazing dancing.

smile for audience.

C. Audience will :

observe talented dance performance by two dance superstars.

applaud after dance performance is completed.

IN CLOSING

Remember, the key to good policy and procedure writing is clarity. Less is often more. "Generous use of white space" is what was recommended to me once. It takes some practice, but once you learn the pattern to good writing, it doesn't need to take too long. In fact, you eventually get to the point where someone is discussing a problem, and you can start to envision the policy and procedure in the top of your head.

This is why good policy writers are worth their weight in gold - Good policies can help you make change, achieve clarity, and save your organization time and money. Bad policies do not make any organizational change, do not achieve any clarity, and will cost your organization in both time and money.

I hope this helps turn you into a policy ninja! Remember, use your powers only for good, and go out there and write good policy!

Would love to hear other people's stories about writing policy and how it related to their EMR implementations! If anyone has any questions, please let me know! :)